Outpatient Medical Rehabilitation and Aged Care Clinics Referral Form 
Private patients are Medicare bulk billed for outpatient clinic services						Please Fax To:
							(08) 8404 2263

Patient details	Date of referral: 	
Surname: <PtSurname>
Given Name(s): <PtFirstName>
Address: <PtAddress>

Postal address (if different from above):
<PtPOAddress>	DOB: <PtDoB>                               Gender: <PtSex>
Telephone: <PtPhoneH>
Mobile: <PtPhoneMob>
Medicare number: <PtMCNo>
MRN: 
Aboriginal <Aboriginal> Torres Strait Islander <Torres Strait Islander> Both <Both Aboriginal/Torres Strait Islander> Neither <Neither Aboriginal/Torres Strait Islander>
Compensable: 
DVA number: <PtDVANo>
Interpreter required: <Interpreter Required>
If yes, language: <If yes, language:>	
GP details		
Name: <DrName>	Contact Number: <DrPhone>	
Substitute decison maker/person responsible/next of kin	
Name: <Substitude decison maker/person responsible: Name>
Contact number: <Substitude decison maker/person responsible: Contact Number>	Relationship: <Substitude decison maker/person responsible: Relationship>
Patient consent to referral: <Patient consent to referral:>	
Please only select the preferred doctor below
4th Generation Outpatient medical only assessment clinics - indicate preferred doctor	
PLEASE NOTE - ALL INITIAL CONSULTS REQUIRE AN IN-CLINIC APPOINTMENT.
TELEHEALTH SERVICES ARE AVAILABLE FOR SUITABLE CLIENTS FOR REVIEW APPOINTMENTS.
SEE *SERVICES BELOW	
REHABILITATION CLINICS
*Driving Fitness Assessment
<Indicate Preferred Doctor - *Driving Fitness Assessment>	
*Neurorehabilitation Clinic
<Indicate Preferred Doctor - *Neurorehabilitation Clinic>	
*Musculoskeletal Rehabilitation
<Indicate Preferred Doctor - *Musculoskeletal Rehabilitation>	
General Rehabilitation (includes chronic stroke)
 <Inidicate Preferred Doctor - General Rehabilitation (includes chronic stroke)>	
Spasticity Clinic
<Indicate Preferred Doctor - Spasticity Clinic>	
Fragility Fracture Service
<Indicate Preferred Doctor - Fragility Fracture Service>	
Youth Rehabilitation Transition Clinic
<Indicate Preferred Doctor - Youth Rehabilitation Transition Clinic>	
Frailty Clinic
<Indicate Preferred Doctor - Frailty Clinic>	
	
4th Generation Outpatient medical only assessment clinics - indicate preferred doctor	
PLEASE NOTE - ALL INITIAL CONSULTS REQUIRE AN IN-CLINIC APPOINTMENT.
TELEHEALTH SERVICES ARE AVAILABLE FOR SUITABLE CLIENTS FOR REVIEW APPOINTMENTS.
SEE *SERVICES BELOW	
AGED CARE CLINICS
Aged Care Clinic (including memory assessment)
<Indicate Preferred Doctor - Aged Care Clinic (including memory assessment)>	
Memory Clinic 
<Indicate Preferred Doctor - Memory Clinic>	
Falls Clinic 
<Indicate Preferred Doctor - Falls Clinic>	
Nursing Home Visits Service
<Inidicate Preferred Doctor - Nursing Home Visits Service>	
Southern Fleurieu Aged Care Clinic
<Indicate Preferred Doctor - Southern Fleurieu Aged Care Clinic>	

Referral information	
Reason for referral: <Reason for Referral>	
Please provide details including PMHx. current medications and allergies, relevant investigations results and social issues:

<VisitReason>
<TodaysVisit>

<SelectedPMH>
<SelectedRx>
<Reactions>

<SocialHx>

Referrer's details	
Name: <UsrName>
Designation: <Practice>
Signature:

Provider no: <DrProviderNo>	Date: <TodaysDate>
Referral period: <Referral Period>
Referring unit: 
Referring Consultant: 
Tel: <DrPhone> Fax: <DrFax>	
     Please phone (08) 8404 2269 if any queries regarding referrals